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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use,by contractors performing annual testing of UST spill containment stnrctures. The completed form and <br /> printouts front tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kaiser Stockton Date of Testing: 6/28/2018 <br /> Facility Address: 7373 West Lane <br /> Facility Contact: Phone:. <br /> Date Local Agency Was Notified of Testing: 6/7/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Belshire Environmental Services, Inc. ENviRONMENTAL <br /> Technician Conducting Test: David Walker Hr—A[,,H IPEWITM <br /> Credentialsl: W CSLB Contractor ❑ICC Service Tech. ❑SWRCB Tank Tester EJ Other(Specify) <br /> License Nuniber(s): 808313 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: d❑Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Visual Equipment Resolution: ±1.00 <br /> -77 777 <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number,Stored Product, etc.) DSL Fill <br /> Bucket Installation Type: Direct Bury <br /> Bucket Diameter: 12" <br /> Bucket Depth: 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 Minutes <br /> Test Start Time(Tr): 9:00 AM <br /> Initial Reading(RI): 1.5"From Top <br /> Test End Time(TF): 10:00 AM <br /> Final Reading(RF): 1.5"From Top <br /> Test Duration(TF—Tl): 1 Hour <br /> Change in Reading(RF-Rt): 0 <br /> Pass/Fail Threshold or No Leaks <br /> Criteria: <br /> Test Result: Pass ❑Fail ❑Pass ❑Fail ❑Pass El Fail ❑Pass ❑ Fail <br /> Comments —(include information on repairs made prior to testing,and r-ecorrmnended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements, <br /> Technician's Signature:. a ujk, Date: 6/28/2018 <br /> State laws and regulations do not currently require testing to be performed by a qualified contractor,However,local requirements <br /> may be more stringent. <br />